**** EMERGENCIES IN ENDODONTICS ****.pptx

Endodontic emergencies by Dr. Sushmita Rane

1. ENDODONTIC EMERGENCIES Dr. Sushmita Rane MDS III Seminar 10 11/12/2023

2. INTRODUCTION An Endodontic emergency is defined as pain and/ or swelling caused by inflammation or infection of the pulp and/or periradicular tissues necessitating an emergency visit to the dentist for immediate treatment. Dental trauma Deep caries Deep/defective restorations

3. Pulpal pathologies Traumatic injuries

4. WHEN DO ENDODONTIC EMERGENCIES OCCUR?

5. CLASSIFICATION OF ENDODONTIC EMERGENCIES

6. According to Grossman: 1.BEFORE TREATMENT (A) ENDODONTIC EMERGENCIES PRESENTING WITH PAIN AND/OR SWELLING ( i ) Crown-originating fracture (COF) (previously known as cracked tooth syndrome) (ii) Symptomatic reversible pulpitis (iii) Symptomatic irreversible pulpitis (iv) Primary symptomatic apical periodontitis (v) Secondary symptomatic apical periodontitis (acute exacerbation of asymptomatic apical periodontitis or phoenix abscess) (vi) Symptomatic (acute) alveolar abscess (vii) Cellulitis ( B) TRAUMATIC INJURIES ( i ) Crown/root fractures (ii) Luxation injuries (iii) Tooth avulsion

7. 2. DURING TREATMENT 2. AFTER TREATMENT (a) Hot tooth (b) Endodontic flare-ups (a) Post obturation pain (b) Vertical root fracture (VRF)

8. ACCORDING TO GUTTMAN: 1.TREATMENT OF VITAL PULP: -Acute reversible pulpitis -Hypersensitivity dentin -Recurrent decay -Recent restorations -Cracked tooth syndrome 2.TREATMENT OF NON VITAL PULP: -Acute apical periodontitis -Necrotic pulp -Acute alveolar abcess -Acute irreversible pulpitis 3. ESTHETIC EMERGENCY -Fracture of crown -Fracture of root -Avulsed tooth

9. ACCORDING TO WALTON:

10. GENERAL MANAGEMENT OF ENDODONTIC EMERGENCIES When managing a patient who presents with pain, the principles of the “Three D’s” should be followed (Kaiser & Byrne, 2011 ). which is The type and details of the treatment depend on the diagnosis of the presenting problem and the amount of remaining tooth structure as this will dictate whether the tooth is suitable for further restoration and how it can be restored. Drugs can be used intra-dentally (sedative liners, root canal medicaments) and as systemic medications, but it is essential to understand that systemic drugs should only be used as an adjunct to the dental treatment. Diagnosis Definitive dental treatment Drugs

11. CROWN ORIGINATING FRACTURES It is a spontaneous fracture originating in the crown and progressing into the root in an apical direction. Incomplete fracture of a tooth with a vital pulp involve enamel and dentin, often the dental pulp The Cracked tooth syndrome was suggested by Cameron and it immediately became accepted by profession for symptomatic teeth with crown fractures.

12. CRAZE LINES : Visible cracks in the enamel that do not extend into dentin and either occur naturally or due to trauma INFRACTION : It is a descriptive term that indicates an incomplete fracture without displacement of the fragments

13. SPLIT TOOTH: describes a fracture that extends through both marginal ridges usually in a mesio -distal direction, splitting the tooth completely into 2 separate segments

14. Characteristics: progressive in nature discontinuity in the integrity of a tooth’s hard tissue Some COFs are the cause of cuspal fractures and these often do not directly involve the pulp. Fracture that are more centrally located on the occlusal surface do involve the pulp. Some are associated with symptoms some are not. Symptoms are vague-Discomfort to chewing - Elevated sensitivity to cold food and drinks

15. INCIDENCE: In maxillary teeth 70% of fracture lines were situated toward the buccal tooth surface, while in the mandibular teeth they were inclined to be towards lingual surface. -COF in mesio -distal direction -More common in mandibular molars -COF in bucco -palatal direction -More common in mandibular molars

16. Anterior teeth is involved in infarction is the result of an injury from a sudden traumatic blow Most cases occur in teeth with class I restorations (39%) or in those that are unrestored (25%) , but with an opposing plunger cusp occluding centrically against a marginal ridge. A C B

17. ETIOLOGY:

18. Seo et al showed that the use of non bonded inlay restoration materials such as gold or amalgam increased the occurrence of longitudinal tooth fractures Another contributing factor has been the use of pins for supporting large restorations, especially self threading and friction lock pins .

19. Clinical examination: 1) VISUAL EXAMINATION : Fiber optic light: Used to transilluminate a fracture line Dye: Methylene blue or red dye Microscope: in combination with dye

20. 2) BITE TEST: Kahler et al explained the pain associated with release of pressure results from fluid movement as the cracks rapidly closes. A very significant response to biting is when pain is experienced on release of biting pressure and referred to as either rebound pain or relief pain A small, pyramid-shaped plastic bite block, with a small concavity at the apex of the pyramid to accommodate the tooth cusp. This small indentation is placed over the cusp, and the patient is asked to bite down. Thus, the occlusal force is directed to one cusp at a time, exerting the desired pressure on the questionable cusp.

21. 3) COLD STIMULUS APPLICATION AND ELECTRIC PULP TESTING (EPT) -will provide information about the status of the pulp and there is evidence that teeth with fractures respond at lower threshold levels to cold and EPT stimulation compared to non fractured teeth. 4)THIN SHARP EXPLORER Using a sharp explorer to probe around the cervical circumference of teeth suspected of having infractions, they may be identified by the ‘click’ when explorer encounters the fracture. Some patients will also feel a sharp, sudden pain at that time.

22. 5) PERCUSSION SENSITIVITY A tooth with infraction is not likely to be identified by percussion until the fracture extends to involve the PDL

23. MANAGEMENT OF CROWN ORIGINATING FRACTURES Reversible pulpitis: Preserve the pulp vitality – Full coverage for cusp protection.

24. Remove fractured segment Restoration of tooth Large crack Pulp involved Small crack Pulp not involved Hopeless prognosis Endodontic therapy + Immediate stabilization with Orthodontic brackets Final Restoration with crown and/or post and core Occlusal adjustments + Immediate stabilization Permanent stabilization using bonded restoration or crown Extraction ASSESSMENT OF TOOTH

25. EMERGENCIES DURING TREATMENT

26. HOT TOOTH A tooth that is difficult to anesthetize is known as a hot tooth Associated with an irreversible pulpitis Inflamed pulp tissue has an extremely concentrated sensory nerve supply particularly in the chamber, it becomes more difficult to anesthetize Associated with mandibular molars following long periods of low level to moderate pain Extremely frustrating to the patient and dentist

27. THEORIES OF HOT TOOTH Hyperalgesia : Inflammation within the tooth alters the actual nerve by changing the resting potentials and decreasing the excitability thresholds making it harder to anesthetize. Nervous patient : Pain threshold further reduces causing difficulty to anesthetize Location : If anesthetic is away from the target, it becomes hard to anesthetize Local tissue changes due to inflammation : In the area of inflammation, acidic pH of inflamed tissue decreases the amount of base form of anesthetic available to penetrate nerve membrane causing low effect.

28. Central core theory : It states that nerves outside the nerve bundle supply the molars whereas nerves on the inside supply the anterior teeth so anesthetic may not penetrate into the nerve trunk to make all the nerves numb. Tetrodotoxin-resistant ( TTXr ) channels : Special class of sodium channels on C- fibers known as TTXr sodium channels, during inflammation, neuroinflammatory reactions start, sodium channel expression on C- fibers shift from TTX-sensitive to TTXr causing hyperalgesia and these channels are 5 times more resistant than TTX sensitive channels.

29. MANAGEMENT OF HOT TOOTH EXPLAINING TO THE PATIENT: use of iatrosedation and verbal sedation PREMEDICATION: Anti-inflammatory 1 hour before the procedure along with time gap between anesthetic injection and starting the procedure (Lorazepam 1 mg after checking interaction with other drugs the night before sleep followed by 90 minutes prior to procedure) Administration of nitrous oxide while dealing with hot tooth

30. SUPPLEMENTAL ANESTHETIC TECHNIQUES Supplementing an inferior alveolar nerve block (IANB) with 4% articaine with 1:100,000 epinephrine buccal infiltration (0.9–1.2 mL) at the apex of the tooth to be treated is one of the most effective supplemental anesthetic techniques. SUPPLEMENTAL INJECTIONs INTRAPULPAL INJECTION

31. INTRALIGAMENTARY INJECTION Special pressure needles have been developed for IL injection with Preset volume (0.14-0.22 mL) with minimal effort. 27 or 30 G needle inserted with positive pressure as deep as possible along the root with the bevel towards the crest. In posteriors, needle is bent to an angle and trigger is squeezed to deliver 0.2 mL Immediate onset and lasts 27 minutes 92% effective

32. PDL injections are usually given using either a standard dental anesthetic syringe or a high-pressure syringe. The development of computer-controlled anesthetic delivery systems (the Wand) or the Single Tooth Anesthesia have been found to be able to deliver a PDL injection.

33. INTRAOSSEOUS INJECTION The use of the intraosseous injection allows the practitioner to deliver local anesthetic solutions directly into the cancellous bone surrounding the affected tooth. There are several 10 systems available in the market

34. The Stabident system consists of a 27-gauge beveled wire that is driven by a slow-speed handpiece, which perforates the cortical bone. Anesthetic solution is then delivered into the cancellous bone through the perforation. The IntraFlow handpiece holds and drives a perforating needle, which is engaged via an internal clutch to deliver the local anesthetic through the perforation.

35. The X-Tip system consists of a 2-part perforator and guide sleeve component which is also driven by a slow-speed handpiece. The perforator leads the guide sleeve through the cortical bone and then is separated from it and removed. This leaves the guide sleeve in place and allows for a 27gauge needle to be inserted for injecting the anesthetic solution.

36. INTRA-PULPAL ANESTHESIA Combination of pharmacologic action of LA and pressure applied during the process. Can only be done if the body of the exposed pulp is large enough to admit a hypodermic needle. 0.2-.03 mL injected into the pulp. Immediate and effective.

37. ENDODONTIC FLARE-UPs An Endodontic flare up is defined as an acute exacerbation of a periradicular pathosis after the initiation or continuation of nonsurgical root canal treatment. Some flare-ups may be iatrogenic and others are not. Development of moderate-severe inter-appointment pain with or without swelling is an infrequent but challenging situation. Severe pain and swelling associated with flare-ups represent the clinical manifestation of complex pathologic changes occurring at a cellular level

38. Etiology 1) MECHANICAL

39. 2) CHEMICAL

40. WORKING LENGTH Correct WL is essential Non-vital teeth associated with a periapical lesion as well as root filled teeth with recalcitrant lesions represent a different biological challenge

41. NON-VITAL TEETH Over instrumentation may force infected debris into the periapical tissues elicitating a severe inflammatory response and pain Underinstrumentation will leave micro-organisms in close proximity to the apical foramina where they or their virulence factors can gain access to tissues Incomplete instrumentation can disrupts the balance within the microflora and allow previously inhibited species to overgrow

42. IRRIGANT EXTRUSION Standard irrigant used is 1-5.25% NaOCl with final rinse of 17% EDTA. Every procedure including irrigation should be a passive procedure extrusion of irrigant beyond the periapex leads to sodium hypochlorite accident Severe pain, swelling and profuse bleeding through the tooth and interstitial tissues

43. SIGNS OF sodium HYPOCHLORITE accident Severe and excruciating pain when not under LA If under LA, Patient complains of irritation at the periradicular area Sudden flooding of the canal with blood and tissue fluids Ballooning of tissues in the area and swelling of soft tissues Edema , ecchymosis with tissue necrosis, parasthesia seen .

44. MANAGEMENT Bleeding is allowed to flow since it is a defense physiological mechanism. Flood the canal with normal saline so that accumulated blood comes out and level of pain decreases Immediate aspiration and application of icepacks Immediately placed on parenteral antibiotics and analgesics Consult general physician and administer steroids in a planned manner Backup vitamin therapy during recovery is recommended

45. PREVENTION Always use passive irrigation Handled carefully Closed ended lateral/side vented 30 G needles are used Never bind the needle in the canal, allow back flow. Oscillate the needle in the canal

46. Tissue emphysema Collection of gas/air in tissue spaces or facial planes Occurs during periapical surgery when air from airotor is directed towards exposed soft tissues. When blast of air is directed towards open root canals to dry them Complication of fracture involving facial skeleton

47. Rapid swelling, edema and crepitus (crepitus pathognomonic of tissue emphysema) Dysphagia and dyspnea and if emphysema spreads to neck, it can cause issues with breathing and progression to mediastinum Differential Diagnosis: Angioedema, internal hemorrhage and anaphylaxis

48. TREATMENT AND PREVENTION Antibiotics to prevent risk and spread of infection Application of moist heat to reduce swelling If airway or mediastinum is obstructed, immediate medical attention and hospitalization of patient. Administration of 100% O2 via mask When using air pressure, blast of air directed at horizontal direction against walls of tooth and root periapically During surgical procedures, use low speed or high speed handpiece which do not direct air towards tissues (rear exhausting handpiece for root resection and ultrasonics for retropreparation )

49. According to Seltzer et al, the microbiological and immunological factors are also responsible for flare-ups

50. Alteration of local adaptation syndrome There is a balance between root canal microflora and the host immune system which is known as local adaptive syndrome. When there is presence of asymptomatic apical periodontitis and we are accidentally pushing debris into the root canal space, there is occurrence of flare-ups. This occurs due to disturbance in this balance A Study showed that when a new irritant is introduced to a chronically inflamed tissue, a violent reaction may occur due to disturbance in local tissue adaptation to applied irritants.

51. Changes in periapical tissue pressure In teeth with increased periapical pressure, exudate creates pain by causing pressure on the nerve endings. Pain is relieved when the tooth is kept open to drain the exudate but in teeth with less periapical pressure if kept open, microbes and other irritants may get aspirated into the periapical area causing pain.

52. Microbial factors Gram negative anaerobes like Prevotella and Porphyromonas species release endotoxins which are neurotoxic. These activate the Hageman factor to release Bradykinin, a potent pain mediator. Teichoic acid which is present in the cell wall and plasma membranes of gram positive bacteria produce humoral antibodies IgM, IgG, IgA and release mediators causing pain

53. Apical extrusion of debris Disrupts the balance between microbial aggression and host defence – acute periapical inflammation

54. Changes in endodontic microflora and/or in environmental conditions : Incomplete chemomechanical preparation disrupts balance between different microbial communities within the root canal system resulting in a flare-up.

55. Secondary intraradicular infection : penetration of new microbial species, microbial cells and substrate from saliva into the root canal system during treatment which may lead to a secondary infection and cause a flare-up.

56. Increase of oxidation-reduction potential: alteration of oxidation-reduction potential during endodontic treatment may favour overgrowth of facultative bacteria that resist chemo-mechanical procedures

57. Tissue Irritation by Effect of Chemical Mediators Chemical mediators are in form of cell mediators, plasma mediators and neutrophils products . Cell mediators include histamine, serotonin, prostaglandins, platelet activating factor, etc . which cause pain. 2) Plasma mediators are present in circulation in inactive precursor form and get activated on coming in contact with irritants.

58. Anxiety, apprehension, fear and previous history of dental experience plays a contributory role in mid-treatment flare-ups I mmunological response In chronic pulpitits and periapical disease, presence of macrophages and lymphocytes indicates both cell mediated and humoral response P sychological factor

59. Strategies to prevent flare ups Over 200 studies indicate that behavioural intervention, to decrease anxiety before and after surgery reduces post operative pain intensity and intake of analgesics improve treatment compliance, cardiovascular and respiratory indices and accelerates recovery Protocols Information about profound anesthesia and preventive strategies is an important anxiety reduction technique. Information about sensation experienced during treatment as well as description of procedures appears to have a significant impact in reducing anxiety. ANXIETY REDUCTION

60. PHARMACOLOGICAL STRATEGIES TO PREVENT FLARE UPS ANTIBIOTICS Not recommended for healthy patients Indicated – 1) Spreading infection that indicates failure of local host responses. 2) Patient with medical condition that compromises defense mechanism. NSAIDS: Pretreatment with NSAIDS for irreversible pulpitis should have the effect of reducing pulpal levels of inflammatory mediator prostaglandin E2 (PGE2)

61. One study found that one or two tablets of single tablet combination of ibuprofen 200 mg/ Acetaminophen 500mg was statistically significantly more effective than two tablets of Acetominophen or one tablet of the ibuprofen/ Acetominophen combination. Combining Ibuprofen + Acetaminophen = provides additional therapeutic strategy for managing pain. It is advisable to take the medications “by the clock” rather than on an “as needed basis”.

62. Treatment of flare ups Flare Ups Iatrogenic Inaccurate WL Necrotic case

63. Pulp necrosis with acute apical abcess No Swelling when treatment is done in more than one visit, Intracanal medicament like calcium hydroxide is placed. Care should be taken not to push necrotic debris during instrumentation Crown down instrumentation have been shown to remove most of the debris coronally rather than pushing it beyond the apex. The use of positive pressure irrigation methods , such as needle and syringe irrigation poses a risk of expressing debris or solution out of the apex. Improvements in technology such as apex locators have facilitated increased accuracy.

64. SWELLING Acute periradicular abcess at the time of the initial emergency visit interappointment flare up postendodontic complication

65. Localized Diffuse The principle modality for managing swelling secondary to endodontic infection is to achieve drainage and remove the source of infection. When the swelling is localized, the preferred avenue is drainage through the root canal. A C B

66. In this manner the canal can be dried and the endodontic treatment completed in one visit In the presence of persistent swelling, gentle finger pressure to the mucosa help in drainage Once the canals cleaned and dried, the access should be closed.

67. Treatment of acute apical abcess Drainage via the root canal and/or incision and drainage of the swelling Consider oral antibiotics if systemic signs of illness (malaise, increased temperature, lymph node involvement, etc.) Non- steroidal anti- inflammatory drugs (e.g. ibuprofen 400 mg every 4– 6 h) and/or Analgesics (e.g. acetaminophen 1000 mg every 4– 6 h)

68. Fascial space infection

69. According to Hohl and colleagues, Fascial spaces of head and neck can be categorized into 4 anatomic groups Swellings of and below mandible include 6 anatomic areas or fascial spaces

70. The Mandibular buccal vestibule is the anatomic area amid the buccal cortical plate and buccinator muscle in posterior of mandible and mentalis muscle in anteriors Space of the body of the mandible: Area between the buccal or lingual cortical plate and overlying periosteum

71. MENTAL, SUBMENTAL SPACES

72. SUBLINGUAL AND SUBMANDIBULAR SPACES The lateral boundaries of the space are the lingual surfaces of the mandible

73. LATERAL FACE SWELLING

74. Buccal vestibular space and buccal spaces

75. Submassetric and temporal spaces

76. ANATOMIC SPACES IN PHARYNGEAL AND CERVICAL AREAS

77. Buccal, submasseteric , pterygomandibular, parapharyngeal spaces Pretracheal, prevertebral and danger spaces

78. MIDFACE SWELLING: ANATOMICAL SPACES IN MIDFACIAL AREA

79. MANAGEMENT OF ABCESSES AND CELLULITIS The emergency treatment of suppurative lesions involve establishing drainage Drainage can be achieved and relieves acute symptoms caused by symptomatic (acute) alveolar abscess by the following protocols:

80. ACHIEVING DRAINAGE THROUGH ROOT CANALS LA is not needed as pulp is necrotic and frequently LA is contraindicated in acutely inflamed tissue as its infiltration does not anesthetize the tissue. Forcing LA into acutely infected and swollen area may increase pain and spread the infection into facial spaces. Local anaesthesia may be administered to reduce the pain of acute alveolar abscess as long as injection route is distant from the inflamed area. Mandibular block or infraorbital block can be used for a few cases where partial vitality persists.

81. If the abscess does not drain through the canal in spite of creating canal patency, canals should be cleaned and shaped to facilitate the placement of an Intracanal medicament. In some cases, it is recommended to place sterile cotton pack in the pulp chamber and make the patient wait for some time for drainage to occur after which the pack can be removed and canals re-irrigated before placing Intracanal medicament, the access is sealed with Cavit G cement. Prescribe analgesics as the patient may have acute pain with accompanying symptoms. After symptoms have subsided, the canals are opened and reassessed before completing root canal therapy.

82. When buildup of exudate is confined to hard tissues, a dull, boring excruciating pressure develops and as it penetrates cortical plate Swelling occurs and pain diminishes when : Swelling creates enough pressure and bone lysis to create a sinus drainage through the bone. This is the phase where the symptomatic acute alveolar abscess becomes an asymptomatic chronic alveolar abscess (OR) • The operator surgically creates an incision in the dependent part of the swelling to facilitate drainage. INCISION FOR DRAINAGE

83. • Fluctuant swellings: When the swelling is localizes into a soft, fluctuant, palpable mass, it should be incised and drained, a procedure that dramatically reduces the swelling and pain. • Indurated swellings: If the swelling remains hard or indurated, then the swollen tissue should be bathed in warm saline rinses for 5 minutes every hour until it becomes soft, fluctuant, and ready for incision.

84. CLINICAL PROTOCOL The clinician should first dry the mucosa over the affected area and then spray the tissue with a refrigerant topical anesthetic . Some clinicians prefer to use a block or peripheral infiltration around but not in the swollen tissues, prior to incision The incision should be made at the most dependent site of the swelling Hemostat or elevator used to dissect the incision site to facilitate drainage

85. Soft tissue compression over the site of the swelling is then performed allowing the abscess to drain through the incised site. Finally, the tooth should be disoccluded slightly if it is extruded from its socket.

86. NEEDLE ASPIRATION Use of suction to remove fluids from a cavity or space Information is gathered regarding presence, type and volume of exudate, cystic fluid or blood in the lesion for definitive diagnosis Administer LA Syringe with 18 G needle used to aspirate the contents out of the swelling

87. A B C

88. CORTICAL TREPHINATION Fully anaesthetized Cortical bone is exposed after placing surgical incision (a closed hemostat may be inserted and opened to enlarge the surgical site) Create an opening in the cortical bone to facilitate drainage: In cancellous bone, it can be achieved with a sharp surgical explorer In harder bone regions, use of surgical high speed round bur would be recommended

89. DECOMPRESSION In large cysts with swelling, a decompression procedure is advocated where a drain tube is inserted into the trephined cyst cavity for several weeks to enable communication between cyst cavity and oral cavity. If the swelling is hard, it can be converted to a soft, fluctuant swelling by rinsing with hot saline solution 3–5 minutes every hour.

90. POST OBTURATION EMERGENCIES

91. POST OBTURATION EMERGENCIES

92. OBTURATION Gross overfilling involves the introduction of excess sealer and its cytotoxic components into the periapical tissues causing tissue damage and inflammation. A study found that overfilling was associated with significantly increased rate of pain and percussion sensitivity in 1 week followup examinations as compared with teeth not overfilled

93. Was the patient symptomatic prior to obturation? If there is swelling, is it localized, diffuse or fluctuant? Is the tooth overfilled? Is pain/swelling increasing ?

94. Obturation in the presence of acute apical periodontitis can be considered to be a predictor of post operative pain. 2) Scheduling of the obturation To Avoid Patients who present with acute apical periodontitis should have the procedure postponed until the tooth is more comfortable

95. 3) If treatment is already done: Relief of pain achieved by treatment directed at reducing tissue levels of factors that stimulate peripheral terminals of nociceptors or by reducing mechanical stimulation of sensitized nociceptors (e.g. OCCLUSAL ADJUSTMENT)

96. Delayed healing and lower success rates are seen when there is overextended obturation. Open apex cases have the potential for overfillings and attempts should be made to maintain apical anatomy small and not unnecessarily enlarge the area Gross overfilling cases prolonged pain and may have serious consequences if vital anatomical structures are involved (complicates removal) Overfilling

97. GP or sealer may extend into the mandibular canal causing severe damage to the IAN and paresthesia Radiographs may be helpful in determining proximity to the mandibular canal. Conventional x-rays may only provide a 2-D image of the relationship between apex and mandibular canal and CBCT provides vastly more information as a 3-D image. CBCT is valuable in determining the relation between apices and floor of the maxillary sinus Filling material extruding into the sinus can potentially cause chronic sinusitis and infection MANDIBULAR CANAL MAXILLARY SINUS

98. OCCLUSAL ADJUSTMENTS A statistically valid profile of patients most likely to benefit from occlusal reduction was developed. In that study of 117 patients, approximately twice as many (80%) with a diagnosis of irreversible pulpitis, who underwent occlusal reduction, reported no post treatment pain when compared to control subjects with no occlusal reduction

99. Occlusal reduction was found to result in prevention of post operative pain when any or all of the following indicators were present Sensitivity to percussion Vital tooth History of pain Absence of periapical lesion

100. REMOVAL OF OBTURATION Filling canals in the presence of symptoms is a predictor of post obturation pain TREATMENT -Pharmaco-therapeutics including analgesics and/or antibiotics (nonvital) to retreatment with or without incision or drainage. -Consider variables and determine if the primary cause is inflammatory, procedural or active infection Depends on the quality of the filling Nature of the swelling – Fluctuant or non-fluctuant

101. RETREATMENT More challenging than primary root canal treatment More prone to exacerbations with a long history of persistent infection with complex flora Microbes found in failed RCT have either remained in the canal following previous treatment or may have entered through the coronal leakage Primary – Polymicrobial organisms dominated by anaerobes Secondary infection – Gram positive principally enterococci

102. An important consideration in retreatment cases is the origin of the intra-canal bacterial flora. The microbial source may be due to a defective restoration or colonies remaining after initial root canal therapy If the cause of bacterial penetration is the restoration, it must be replaced Microbes remaining after root canal therapy must be addressed

103. E. faecalis Gram-positive facultative bacteria, particularly are predominant This virulent microbe is particularly difficult to eliminate due to its resistance to calcium hydroxide, and it can survive without nutrition for long periods of time. More likely to be found in cases of failed endodontic therapy than in primary infections Resistance to calcium hydroxide may be due to a gene involved in cell division which enables it to survive following prolonged exposure to alkaline pH asymptomatic cases symptomatic ones

104. PREDICTORS OF PERSISTENT PAIN

105. POSSIBLE CAUSES OF PERSISTENT PAIN

106. VERTICAL ROOT FRACTURE According to the American Association of Endodontists , a “true” vertical root fracture is defined as a complete or incomplete fracture initiated from the root at any level, usually directed buccolingually” 2.3% in total fractured teeth and highest incidence in Endodontically Treated Teeth of patients older than 40 Most common causes – Excessive dentin removal during BMP and weakening of tooth during post space preparation

107. PREDISPOSING FACTORS Anatomy of root Amount of remaining tooth structure Presence of pre-existing cracks Loss of moisture in dentin During obturation

108. PATHOGENESIS

109. CLASSIFICATION

110. PREVENTION Avoid weakening of canal walls Minimize internal wedging forces Evaluate tooth anatomy before treatment Preserve as much as tooth structure as possible before treatment Use optimal forces during obturation for compaction of GP Use posts with passive fits and round edges to reduce stress concentration

111. CONCLUSION The management of endodontic emergencies is an important part of a dental practice. The patients usually have significant pain that requires immediate and comprehensive management. If the principles are followed, then the presenting problem and the pain are highly likely to resolve. However, if the pain has continued, then reassessment of the new problem must be undertaken so that the management can be reconsidered in the light of the revised diagnosis. Methodical diagnosis and prognostic assessment are imperative, with the patient being informed of the various treatment alternatives.

112. References: Paul V. Abbott Present status and future directions: Managing endodontic emergencies Int Endod J. 2022;55(Suppl. 3):778–803. DOI: 10.1111/iej.13678 Cohen’s pathways of pulp Ingle’s textbook of endodontics Endodontic pain by Paul A. Rosenberg González-Martín, Maribel et al. “Inferior alveolar nerve paresthesia after overfilling of endodontic sealer into the mandibular canal.”  Journal of endodontics  36 8 (2010): 1419-21. TheHotToothDilemma Vol4 Issue 2 CODS-Sept 2012

113. THANKYOU!